[Mapping of risks related to medication care in nursing homes: An overview in Alsace - France]. / Cartographie des risques liés à la prise en charge médicamenteuse en EHPAD : état des lieux en région Alsace - France.

BACKGROUND: Medication care of patients in nursing homes involves a complex circuit whose related risks need to be identified. The aim of this study was first to map risks related to medication care in a representative panel of nursing homes under contract with community pharmacies in Alsace, then to propose improvement action plans to remedy the weaknesses identified. METHODS: This study was conducted on a representative sample of 23 nursing homes in Alsace in 2014. A self-assessment questionnaire (Interdiag EHPAD), divided into 7 fields and made up of 198 questions, was completed by each of the 23 nursing homes during multidisciplinary meetings that were organized by the OMEDIT (observatoire du médicament, des dispositifs médicaux et de l'innovation thérapeutique of Alsace). The percentages of controlled risks were calculated for each of the 7 fields of the medication circuit, both at nursing home and regional levels. Similarly, the percentages of non-controlled risks were calculated for each of the 198 items. RESULTS: Considering the 7 fields, regional percentages of controlled risks varied from 63% to 85%. The field relative to drug supply was the best controlled, while that relative to prevention was the least controlled. Considering the 198 items, 30 important vulnerability points were identified, among which stand out: failure to report and to analyze adverse drug events, lack of involvement of general practitioner in nursing homes through collaborative approaches and transcription by nurse staff of oral or handwritten prescriptions in medical software. The analysis of those items led to the proposal of 13 improvement actions. CONCLUSION: The study pointed out mainly difficulties linked to the absence of suitable risk management policies and the lack of adjustment between nursing home staffs and general practitioners. In contrast, it revealed that the collaboration between nursing homes and community pharmacies was successful overall. Finally, we hope that this multi-center study, that led to identify concrete proposals, will help nursing homes to improve the quality of medication care for their residents.

[Multidisciplinary care during peripartum: mother-baby dyad in the center of the relational constellations]. / Prise en charge multidisciplinaire du péripartum: le lien mère-bébé au centre des constellations relationnelles.

Pregnancy and new motherhood may be crisis and vulnerability periods and therefore increase the risk of psychiatric disorders. Liaison psychiatry plays a major role in the first psychiatric evaluation of mothers in order to specify a diagnosis and to initiate a treatment when necessary. This article describes the care of mothers suffering from peripartum psychiatric disorders by the liaison psychiatry in the maternity ward, an outpatient practice, as well as an in-patient care unit where mother and baby can stay together. The multidisciplinary approach and its constellation around the mother-baby dyad are detailed and two clinical cases are reported.

[Benefits of routine psychological counselling for patients living with HIV]. / Bénéfices d'un accompagnement psychologique des patients vivant avec le VIH.

Despite improvement of life expectancy of human immunodeficiency virus (HIV) infected people since the implementation of antiretroviral treatment, psychological suffering prevails and needs to be considered as part of the treatment to guarantee its efficiency. Mental disorders and social stigmatization substantially affect patients' quality of life and their adherence to treatment. The article details the benefits of a routine screening for mental disorders within this population, who is often reluctant to consult psychiatric services. The different treatments provided by the Geneva University Hospital (HUG) are introduced. A clinical case report illustrates the relevance of a multidisciplinary care program and the role of the liaison psychiatry in this field.

[Expert assessment in cases of osteoporosis]. / Begutachtung bei Osteoporose.

There are about 8 million people in German-speaking countries who suffer from osteoporosis, making it the most common bone disease. Osteoporotic fractures can significantly impair quality of life and working ability in those affected, and they also give rise to huge expenditures in the healthcare system. Expert assessments should be based on estimated risk of fracture, risk of falling, pain, fitness for work, degree of disability, need for rehabilitation, and causality.

Assessment of vitamin D and calcium status in healthy adult Austrians.

BACKGROUND: Because there is reason to assume that also in Austria calcium and vitamin D malnutrition is wide-spread, we initiated a comprehensive study on calcium and vitamin D status in relation to bone health in a large group of the normal adult population. SUBJECTS AND METHODS: We assessed dietary calcium and vitamin D intake, serum concentrations of Ca2+, phosphate, alkaline phosphatase, 25(OH)D, 1,25(OH)2D, parathyroid hormone (PTH), follicle-stimulating hormone (FSH), sex hormones and bone mineral density (BMD) by double-energy X-ray absorptiometry at five different skeletal sites in 648 females and 400 males (age 21-76 years). RESULTS: Mean daily intake of vitamin D (101 IU, range 0.2-320) and calcium (569 mg, range 40-2170) was significantly less than the respective recommended dietary allowances. Two hundred and seventy-one (26%) individuals had hypovitaminosis D with serum 25(OH)D < 12 ng mL(-1), while serum Ca2+ was less than normal in 82 (7.8%) subjects. Multiple regression analysis revealed significant correlations between mean calcium intake and BMD in the femoral region in the men (r = 0.13, P < 0.05) though not in the women. No consistent data could be obtained for associations between BMD and vitamin D status, except for 25(OH)D and BMD at the spine in the men (r = 0.10, P < 0.05). 25(OH)D correlated negatively (P < 0.05) with age in the women (r = -0.11) and with PTH in the women (r = -0.11) and men (r = -0.16). Inversely, a significant (P < 0.001) age-related increase in PTH was observed in both sexes (men, r = 0.19; women, r = 0.14). CONCLUSIONS: Prevalence of hypovitaminosis D in adult Austrians is an imminent risk for development of secondary hyperparathyroidism with advancing age, and requires timely correction of nutritional deficits.

[Immunologic control of HIV-1 infection. Fantasy or soon reality?]. / Immunologische Kontrolle der HIV-1-Infektion. Wunschtraum oder bald Realität?

The human immunodeficiency virus-1 (HIV-1) preferentially infects CD4+ cells, leading to their destruction. In contrast to other viral infections, the immune system is unable to keep the HIV infection under permanent control in most cases. This failure ultimatively results in immunodeficiency with occurrence of AIDS-defining diseases. In recent years, highly active antiretroviral therapy (HAART) has become available, and the number of AIDS cases and deaths have decreased dramatically. However, limitations of HAART become more apparent, demanding greater emphasis on search for alternative approaches. Stimulation and modulation of the immune response to HIV are new and promising strategies. A prerequisite, however, is the knowledge about immunologic defense mechanisms against HIV. In this article, the major factors of innate and acquired immune responses to HIV are described.

[Cost-effectiveness of PET in the management algorithms of lung tumors: comparison of health economic data]. / Kosteneffektivität der PET im Behandlungsalgorithmus der Lungentumoren: Ein Vergleich gesundheitsökonomischer Daten.

Modelling is an accepted, valid and often necessary method for assessing economic effectiveness in terms of cost per life year gained. Comparing an alternative strategy (a) with a baseline strategy (bl), the incremental cost (COSTa-COSTbl) divided by the incremental life expectancy (LEa-LEbl) defines the incremental cost-effectiveness ratio (ICER). Taking watchful waiting as the low-cost baseline strategy for the management of solitary pulmonary nodules, the ICER of positron emission tomography (PET) [3218 euros (EUR) per life year saved (LYS)] was more favourable than that of exploratory surgery (4210 EUR/LYS) or that of transthoracic needle biopsy (6120 EUR/LYS). Changing the baseline strategy to exploratory surgery, the use of PET led to cost savings and additional life expectancy in case of an intermediate pretest probability of malignancy. For management of potentially operable non-small cell lung cancer the use of PET in patients with normalisized mediastinal lymph nodes on CT was most cost-effective (143 EUR/LYS), and the costs of PET were almost balanced by a better selection of patients for beneficial cancer resection. Using PET in patients with enlarged lymph nodes on CT, the ICER raised to 36,667 EUR/LYS. When PET or CT were positive for mediastinal lymph nodes, the exclusion from biopsy confirmation led to cost savings that did not justify the expected reduction in life expectancy. Economic data from the USA and Japan also demonstrated the cost-effectiveness of PET-based algorithms for the management of lung tumours.

Cost-effectiveness of FDG-PET for the management of potentially operable non-small cell lung cancer: priority for a PET-based strategy after nodal-negative CT results.

Decision analysis is used here to establish the most cost-effective strategy for management of potentially operable non-small cell lung cancers (NSCLCs). The strategies compared were conventional staging (strategy A), dedicated systems of positron emission tomography (PET) using fluorine-18 fluorodeoxyglucose (FDG) in patients with normal-sized (strategy B) or in patients with enlarged mediastinal lymph nodes (part of strategy C), and FDG-PET followed by exclusion from surgical procedures when both computed tomography (CT) and PET were positive for mediastinal lymph nodes (strategy D) or when PET alone was positive (strategy E). Based on published data, the sensitivity and specificity of FDG-PET were estimated at 0.74 and 0.96 for detecting metastasis in normal-sized mediastinal lymph nodes, and at 0.95 and 0.76 when these lymph nodes were enlarged. The calculated probability of up-staging to M1 by using PET was 0.05. The costs quoted correspond to the cost reimbursed in 1999 by the public health provider in Germany. The incremental cost-effectiveness ratio (ICER) of strategy B was much more favourable (143 EUR/LYS; LYS = life year saved) than the ICER of strategy C (36,667 EUR/LYS). In strategy B, the use of PET did not raise the overall costs because the costs of PET were almost balanced by a better selection of patients for beneficial cancer resection. The exclusion from biopsy confirmation in strategies D and E led to cost savings that did not justify the expected reduction in life expectancy. In sensitivity analyses, the ICERs of strategy B were robust to the pretest likelihood of N2/N3, to penalized test parameters of PET and to reimbursement of PET. However, the ICER of strategy B would be raised to 28,000 EUR/LYS through use of thoracic PET without whole-body scanning. To conclude, the implementation of whole-body PET with a full ring of detectors in the preoperative staging of patients with NSCLC and normal-sized lymph nodes is clearly cost-effective. However, patients with nodal-positive PET results should not be excluded from biopsy.

Cost-effectiveness of FDG-PET for the management of solitary pulmonary nodules: a decision analysis based on cost reimbursement in Germany.

Management of solitary pulmonary nodules (SPNs) of up to 3 cm was modelled on decision analysis comparing "wait and watch", transthoracic needle biopsy (TNB), exploratory surgery and full-ring dedicated positron emission tomography (PET) using fluorine-18 2-fluorodeoxyglucose (FDG). The incremental cost-effectiveness ratios (ICERs) were calculated for the main risk group, a cohort of 62-year-old men, using first "wait and watch" and second exploratory surgery as the baseline strategy. Based on published data, the sensitivity and specificity of FDG-PET were estimated at 0.95 and 0.80 for detecting malignancy in SPNs and at 0.74 and 0.96 for detecting metastasis in normal-sized mediastinal lymph nodes. The costs quoted correspond to reimbursement in 1999 by the public health provider in Germany. Decision analysis modelling indicates the potential cost-effectiveness of the FDG-PET strategy for management of SPNs. Taking watchful waiting as the low-cost baseline strategy, the ICER of PET [3218 euros (EUR) per life year saved] was more favourable than that of exploratory surgery (4210 EUR/year) or that of TNB (6120 EUR/year). Changing the baseline strategy to exploratory surgery, the use of PET led to cost savings and additional life expectancy. This constellation was described by a negative ICER of -6912 EUR/year. The PET algorithm was cost-effective for risk and non-risk patients. However, the ICER of PET as the preferred strategy was sensitive to a hypothetical deterioration of any PET parameters by more than 0.07. To transfer the diagnostic efficacy from controlled studies to the routine user and to maintain the cost-effectiveness of this technology, obligatory protocols for data acquisitions would need to be defined. If the prevalence of SPNs is estimated at the USA level (52 per 100,000 individuals) and assuming that multiple strategies without PET are the norm, the overall costs of a newly implemented PET algorithm would be limited to far less than one EUR per member of the public health provider in Germany.

Collection efficiencies of CD34+ progenitor cells and mononuclear cells in leukapheresis products quantified by flow cytometry and calculated on the basis of a new formula.

BACKGROUND AND OBJECTIVES: Optimal mobilization and harvest of hematopoietic progenitors are essential for peripheral blood stem cell transplantation after myeloablative high-dose chemotherapy. Conflicting data have been published concerning the most useful, cost-effective collection strategy which is also convenient for patients. MATERIALS AND METHODS: A total of 66 leukaphereses in 20 patients were retrospectively evaluated. We assessed the predictive value of the number of white blood cells, mononuclear cells (MNCs) and CD34+ cells in peripheral blood for the yield of CD34+ cells in leukapheresis products. The concentrations of MNCs and CD34+ cells were quantified simultaneously by a flow cytometric procedure using fluorescent microparticles. Their collection efficiencies were calculated based on a newly developed formula. RESULTS: The collected hematopoietic progenitor concentration could be predicted only by the number of peripheral blood CD34+ cells prior to apheresis (r = 0.902; p<0.01). Furthermore, the mobilization of at least 30 CD34+ cells/microl peripheral blood was a good predictor that a single leukapheresis would yield a minimum of 2.0x10(6) CD34+ cells/kg body weight. The collection efficiencies calculated by the new formula were 55.2+/-10.7% and 57.7+/-11.2% for MNCs and CD34+ cells, respectively. CONCLUSION: The precise quantification of MNCs and CD34+ cells by a direct flow cytometric assay, as well as the new formula to determine the collection efficiencies, has an impact on optimizing high-quality stem cell products.

[Therapy of osteoporosis: strategies for individualized treatment]. / Therapie der Osteoporose: Strategien für eine individuelle Behandlung.

Pharmacological and non-pharmacological interventions are available and useful for effective treatment of osteoporosis. Drugs act by stimulation of bone formation (fluoride) or inhibition of bone resorption (calcium, vitamin D compounds, bisphosphonates, hormone replacement therapy, calcitonin). Published data for effectiveness on bone mineral density and/or fracture rates vary considerably. Non-pharmacological interventions to prevent falls or the impact of falls (hip protectors) must be part of a sufficient treatment strategy. Costs of treatment have to be considered in comparison to costs of fracture repair and rehabilitation.

Occupational obstructive airway diseases in Germany.

In industrialized countries, occupational asthma caused by allergens and irritants due to workplace exposure is increasing. More than 8,000 such claims were made in Germany (10.5% of all decided occupational disease claims) in 1995; 1,900 were confirmed (6.5% of all confirmed claims). The legal basis and the occupational disease-related regulations of trade-assigned statutory accident insurance institutions ('Berufsgenossenschaften') in Germany are described. Hitherto, three occupational disease categories for obstructive airway disorders existed: due to sensitizing agents, due to chemical-irritative or toxic agents, and due to isocyanates. Approximately 40% of accepted claims for occupational asthma and rhinitis result from exposure to flour. Ongoing changes in the recognition of work-related airway disease symptoms account for differences in the incidence and prevalence as reported over the years. Recently, chronic obstructive bronchitis and/or emphysema of hard coal miners have been included in the German list of occupational diseases.

Achieving sustainable agriculture through recognizing gender roles: some salient points.

PIP: This paper assesses existing gender relations in agriculture with the view that the gender issue must be explicitly appraised and incorporated into development planning in order to achieve environmentally sustainable agriculture. The paper opens with a discussion of the reasons why women are more affected by poverty than men, a brief review of studies indicating that men are more privileged than women and children in almost all societies, and the emerging understanding that women have always been involved in sustaining food security. The next section considers the importance of agriculture for sustainable development and for economic development in general. The paper continues with a brief review of women's status in various societies as revealed by anthropological, archeological, and historical evidence. Gender analysis is seen as essential for solving agricultural and environmental problems because it exposes inequality, exploitation, or oppression and leads to a proper acknowledgement of women's role in agriculture. After a review of the results of studies of gender differences in agriculture, the paper points to the importance of considering the managerial role of women in agricultural production and their use of natural resources as well as their role as laborers. In conclusion, it is recommended that a research agenda be composed to: 1) apply a gender analysis to the history of agricultural civilization; 2) emphasize the difficulties associated with measuring, appraising, and recording time expended; 3) focus on the full range of activities, work, and duties in a typical farming community; 4) determine the likely desirable variant of gender diversity in a given culture; and 5) develop focused, comprehensive research designs that will facilitate compatibility assessment, verifiability, and replicability.^ieng

[Cost analysis of thyroid gland surgery in a university surgical clinic]. / Kostenanalyse der Schilddrüsenchirurgie in einer chirurgischen Universitätsklinik.

On 1 January 1996, the implementation of the new recompense system, the Bundespflegesatzverordnung (BPflV), at the Medical University Halle replaced the former German hospital financing system based on clinic-dependent individual prices. This was the beginning of a new price-performance system of the German hospital market. Since then, for all surgical procedures (catalogue section 301 SGB V ICPM 5061-5064) for benign and malignant thyroid diseases a detailed cost analysis has been performed. Our personnel and material inputs were documented on-line in the operating theatre on a special designed cost-analysis record. The cost analysis was based on 14 cases of lobectomy (average operative costs DM 1886.82), and 20 each of bilateral subtotal thyroidectomy (average DM 1970.48), unilateral subtotal thyroidectomy with contralateral lobectomy (average DM 2164.26) and total thyroidectomy (average DM 2396.70) respectively. In 12 cases the costs of total thyroidectomy with cervical and transthoracal lymphadenectomy have been analyzed (average DM 4664.48).

Large genetic change at small fitness cost in large populations of Drosophila melanogaster selected for wind tunnel flight: rethinking fitness surfaces.

The fitness effects of extreme genetic change by selection were studied in large populations subjected to prolonged, intense selection. Two replicate populations of Drosophila melanogaster, with estimated effective sizes 500 < or = Ne < or = 1000, were selected for increased performance in a wind tunnel, selecting on average the fastest 4.5% of flies. The mean apparent flying speed of both lines increased from approximately 2 to 170 cm/sec and continued to respond at diminishing rates, without reaching a plateau, for 100 generations. Competitive fitness tests in generations 50 and 85 showed minimal or no fitness loss in selected lines compared to controls. Sublines relaxed in generations 65 and 85 showed minimal or no regression in apparent flying speed. Hybrid lines, from a cross of selected x control lines in generation 75, responded to reselection saltationally, showing that the chromosomes of the selected lines had been assembled from alleles at many loci, from many different chromosomes in the base population. Thus, major genetic change was achieved, but without the costs usually associated with strong directional selection. Large population size has been interpreted, in opposing models, as either a brake or an accelerator in its effects on long-term change by selection. These results favor the second model, and challenge the concept of rugged fitness surfaces underlying the first model.

Issues in natural resources management in developing countries.

PIP: The use and management of public and private natural resources is greatly affected by institutional, politicoeconomic, and socioeconomic factors. These factors operate in tandem at the household, regional, national, and international levels in affecting resource management. Any policy that focuses only on one dimension of the problem, such as population growth, and ignores such issues as poverty, environmentally unsuitable cropping systems, and the unavailability of nonfarm employment opportunities will be inadequate. National policies must consider structural factors: resource use, property rights regimes, poverty, unemployment, illiteracy, and population growth. A comprehensive strategy should account for these structural features, be tailored to regional circumstances, and have the input of local governments. Local governments and communities must be in a position to implement and monitor resource management. Hardin identified common property as a major contributor to land degradation and declining forest resources in developing countries. Only with a common agreement by the community to invest in planting trees and managing pastures can communal lands benefit multiple users in the long and short run. Social forestry projects have failed due to poor community participation, fragmented communities, poor social organization, and disputes over the distribution of profits. Traditional communal hunting and gathering activities adhered to institutional regulation; with the inception of urbanization, industrialization, and monetization of agriculture, the destruction of forests and pasture began. There was an increased need for food for the urban population; a small and powerful group of politicians, social leaders, and administrators retained access to public or "crown" lands and disenfranchised small and marginal farmers and the landless poor from previously accessible lands. Land redistribution schemes have not effectively distributed land resources. Commercial business and forestry managers are all responsible for deforestation. Land management is affected by personal, perceptual, attitudinal, social, economic, and institutional factors.^ieng

Reflection of Confucianism, Hinduism, and Buddhism on gender relations and gender specific occupation in Thai society.

PIP: It is posited that present-day Thai society is the product of different settlement patterns among Chinese Confucian followers and those ascribing to matrilocal practices. Chinese settled in urban areas and maintained Confucian dogma that barred women from high ranking positions and dictated a women's role of subservience to men. Matrilocal systems proliferated in rural areas. The village kinship system was egalitarian, until a class-state society was instituted and patriarchal systems dominated. At that time, women's status was reduced. Massive Chinese immigration occurred during the mid-19th century until World War II. Some Indians also migrated during this time period. The dominant use of the Thai language forced the Chinese to assimilate into Thai culture. Thai Buddhist practices were open and similar enough to Confucian ideology that religious assimilation also occurred. A small group of Chinese immigrants retained their ties to Chinese customs. The pattern of foreigners' involvement in the Thai economy was promoted by official policy. In the last several decades Thai policy shifted to an increasingly Thai-influenced economy. Other influences on gender patterns and Thai culture were the Hinduism of Indians who settled in Central Siam, the Mon aristocracy, and Brahmin cults. After the Khmers took over control of this region, the Indian caste system and the Hindu belief in Manu were integrated into Khmer culture. Women were considered the weaker and inferior sex and dependent upon men. The kings of Siam followed Brahmin rituals after the 15th century. Buddhism and the "sangha" became the central Thai religious institution. Even today Buddhist monks are given 3 months time off with pay for time spent as a monk, while maternity leave for women is limited to 45 days. The status of women is traced during the Sukothai period (1250-1350), the Ayudhaya period (1350-1767), and the Ratanakosin period (since 1782). Present occupational patterns reflect women's dominance in business trades and men's dominance in bureaucratic and political affairs. Current patterns reflect gender occupation specialization that is tied to historical patterns linked to religion and ideology.^ieng

[Psychology in the context of medical expert assessment]. / Psychologie im Kontext medizinischer Begutachtung.

One of the tasks of the Medical Service of the compulsory health insurance system in Germany is to conduct follow-up examinations if an employee has been unfit for work for a prolonged period. This involves problems of expertise that are discussed in the present article from the viewpoints of definition, problems and psychological skill in the handling of each individual case. Good interaction between all the parties concerned proves to be an important factor to ensure sociomedical effectivity and to relieve tensions.